Provider Demographics
NPI:1275544348
Name:LABERNIK, MARY SUE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUE
Last Name:LABERNIK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CLOVER CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4954
Mailing Address - Country:US
Mailing Address - Phone:320-654-0242
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-255-6322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR044173-7363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology